01Approach to the Critical Patient/attcp68

Immediate priorities

›Airway and breathing threats

›High-energy mechanism with respiratory compromise

›Tension pneumothorax concurrent with aortic injury

›Hemothorax causing ventilatory impairment

›Flail chest with paradoxical movement

›Immediate intubation triggers

›GCS < 8 or inability to protect airway

›SpO2 < 90% unresponsive to supplemental oxygen

›Respiratory rate > 35 per minute with fatigue

›If intubating, use RSI with hemodynamic-safe agents

›Ketamine or etomidate as induction agent

›Avoid succinylcholine if crush injury with hyperkalemia risk

›Circulation and hemorrhagic shock

›Hemorrhagic shock recognition

›Hypotension present in 17-20% on ED arrival

›Tachycardia with altered mental status

›Base deficit > 6 mmol/l as surrogate of hemorrhage severity

›Permissive hypotension for grade IV before hemorrhage control

›Target MAP 50-65 mmHg until operative control

›Avoid aggressive crystalloid resuscitation

›Activate massive transfusion protocol for grade IV

›1:1:1 ratio packed red cells, FFP, platelets

›Tranexamic acid 1 g IV within 3 hours of injury

›Hemodynamic targets for grades I-III

›Anti-impulse therapy targets

›Heart rate < 60 beats per minute

›Systolic blood pressure 100-120 mmHg

›Mean arterial pressure 70-80 mmHg

›Arterial line placement for continuous titration

›Right radial preferred if left subclavian involved

›Bilateral arm pressures to detect pseudocoarctation

Key decision points

›Grade-based management branching

›Grade I intimal tear: nonoperative with anti-impulse therapy

›Repeat CTA at 24-48 hours to assess progression

›Injury progression rate approximately 7.6% on surveillance

›Grade II intramural hematoma: nonoperative unless high-risk features

›High-risk features favor TEVAR

›Posterior mediastinal hematoma > 10 mm

›Lesion-to-normal aortic diameter ratio > 1.4

›Pseudocoarctation or left hemothorax

›Grade III pseudoaneurysm: TEVAR first-line

›Delay > 24 hours acceptable if patient stable

›Earlier repair justified with concurrent TBI to allow BP liberation

›Grade IV free rupture: emergent operative intervention

›TEVAR if anatomically suitable

›Open thoracotomy with aortic cross-clamping if TEVAR not feasible

Team activation and consult triggers

›Immediate surgical consultation

›Vascular surgery or cardiothoracic surgery for all confirmed BTAI

›Do not delay for hemodynamically unstable patients

›Class I recommendation per 2022 ACC/AHA guidelines

›Trauma surgery for polytrauma coordination

›Competing injury priorities require multidisciplinary triage

›Neurosurgery if concurrent TBI present

›Blood pressure targets diverge with combined injuries

›Transfer triggers

›Transfer to aortic repair-capable trauma center if not already present

›Class I recommendation per ACC/AHA 2022

›Do not delay anti-impulse therapy during transfer

PEARLS

›Clinical pearls for BTAI

›Normal CXR does NOT exclude BTAI

›Classic findings present in only 57.6% of confirmed cases

›Mediastinal widening found in only 27.7% overall

›CTA chest is the definitive test with sensitivity approaching 100%

›NPV of 100%; accuracy 99.7%

›Absence of chest pain does not exclude BTAI

›Low-grade intimal tears may be completely asymptomatic

›NPO status mandatory for all suspected BTAI

›Anticipate operative intervention regardless of grade

02History/hx54

Mechanism of injury

›High-energy deceleration events

›Motor vehicle collision

›Lateral impact carries highest aortic injury risk

›Frontal impact with high speed

›Unrestrained occupant

›Airbag non-deployment or failure

›Steering wheel deformity

›Ejection from vehicle

›Fall from height

›Height of fall

›Landing surface

›Motorcycle or bicycle crash

›Direct thoracic impact

›Pedestrian struck by vehicle

›Speed of vehicle at impact

›Side-impact crashes account for approximately 44% of fatal traumatic aortic ruptures

Presenting symptoms

›Symptom spectrum by injury grade

›Asymptomatic

›Possible with grade I intimal tear

›Discovered incidentally on trauma pan-scan

›Chest pain

›Anterior chest or retrosternal

›Interscapular back pain

›Dyspnea

›From hemothorax or concurrent pulmonary injury

›Neurologic symptoms

03Physical Exam/exam54

Vital signs

›Hemodynamic snapshot

›Blood pressure in both arms

›Upper extremity hypertension with lower extremity hypotension indicates pseudocoarctation

›Radial-femoral pulse delay

›Heart rate

›Tachycardia as hemorrhagic shock marker

›Relative bradycardia with beta-blocker effect

›Respiratory rate

›Elevation with hemothorax or tension pneumothorax

›Oxygen saturation

›Decline with hemothorax or pulmonary contusion

Chest and cardiovascular exam

›Chest wall inspection

›Seatbelt sign

›Diagonal mark across anterior chest

›High association with mediastinal injury

›Steering wheel imprint on sternum

›Sternal fracture association

›Cardiac contusion risk

›Ecchymosis over sternum or anterior chest

›Rib fracture palpation

›Flail segment paradoxical movement

›Cardiovascular findings

›Harsh systolic murmur in interscapular region

›Classic sign of aortic disruption

›Turbulent flow through disrupted aortic wall

›Diminished or absent femoral pulses

04Differential Diagnosis/ddx45

Life-threatening mimics

›Must-not-miss diagnoses

›Traumatic hemothorax

›ICD-10 S27.1

›From rib fractures, intercostal vessels, or lung laceration

›Most common cause of mediastinal widening mimic

›Diagnosis by CXR or chest ultrasound; treated with thoracostomy

›Cardiac contusion with tamponade

›ICD-10 S26.01

›ECG changes, troponin elevation, and tamponade physiology

›FAST diagnostic for pericardial effusion

›Tension pneumothorax

›ICD-10 S27.0

›Hypotension with absent breath sounds and tracheal deviation

›Clinical diagnosis requiring immediate needle decompression

›Free aortic rupture grade IV

›ICD-10 S25.01

›Rapidly fatal without emergent operative intervention

›Presents as refractory hemorrhagic shock

Secondary vascular and mediastinal diagnoses

›Thoracic great vessel injuries

›Subclavian artery injury

›ICD-10 S25.1

›Pulse deficit in ipsilateral arm

›Expanding supraclavicular hematoma

›Innominate artery injury

›ICD-10 S25.0

›Right arm pulse deficit

05Laboratory Tests/lt46

Immediate resuscitation labs

›Type and crossmatch

›Immediate priority in all suspected BTAI

›Anticipate massive transfusion requirement

›Activate blood bank for type O uncrossmatched blood in grade IV

›Complete blood count

›Baseline hemoglobin and hematocrit

›Serial hemoglobin every 4-6 hours in nonoperative grades

›Target hemoglobin > 70 g/l in hemodynamically stable patients

›Target hemoglobin > 80 g/l in ongoing hemorrhage

›Coagulation panel

›PT/INR and PTT

›DIC screening in massive hemorrhage

›INR > 1.5 indicates coagulopathy requiring FFP

›Fibrinogen level

›Target fibrinogen > 1.5 g/l during resuscitation

›Cryoprecipitate if fibrinogen < 1.0 g/l

Metabolic and perfusion markers

›Lactate

›Serum lactate as shock severity marker

›Lactate > 4 mmol/l indicates severe hypoperfusion

›Serial lactate clearance guides resuscitation adequacy

›Failure to clear within 2 hours predicts worse outcomes

›Arterial or venous blood gas

›Acid-base assessment

›Base deficit correlates with hemorrhage severity

›Base deficit > 6 correlates with Class III-IV hemorrhage

›pH < 7.2 with hemorrhage indicates critical state

06Diagnostic Tests/dt86

Scoring Systems

›SVS/Estrera Aortic Injury Grading System

›Grade I: intimal tear

›Focal intimal disruption without periaortic hematoma

›Management: nonoperative with anti-impulse therapy

›Follow-up CTA at 24-48 hours

›Grade II: intramural hematoma

›Blood in aortic wall without pseudoaneurysm

›High-risk features favor TEVAR over observation

›Posterior mediastinal hematoma > 10 mm

›Lesion-to-normal aortic diameter ratio > 1.4

›Grade III: pseudoaneurysm

›Contained extraluminal blood beyond aortic wall

›TEVAR first-line when anatomy suitable

›Delayed repair > 24 hours acceptable if hemodynamically stable

›Grade IV: free rupture

›Uncontained hemorrhage into mediastinum or pleural space

›Emergent operative intervention required

›30-day mortality without repair approaches 100%

›Shock class grading for hemorrhagic shock

›Class I: blood loss < 750 ml, HR < 100

›Class II: blood loss 750-1500 ml, HR 100-120

›Class III: blood loss 1500-2000 ml, HR 120-140, altered mental status

›Class IV: blood loss > 2000 ml, HR > 140, obtunded

MRI

›MRI considerations in BTAI

›Role of MRI in acute setting

›Not recommended as primary diagnostic modality for acute BTAI

›Time prohibitive in unstable polytrauma patients

›Metal implants and monitoring equipment preclude use in critical patients

›Potential late role

›MRI aorta for chronic post-traumatic pseudoaneurysm characterization

›Assessment of spinal cord ischemia as complication

›MRA as radiation-free follow-up alternative in young patients

›Spinal cord ischemia evaluation

›MRI spine to characterize extent of cord injury post-TEVAR

›Guides CSF drainage decision and prognosis

CT

›CT angiography of the chest

›Gold standard diagnostic modality

›Sensitivity approaching 100% for BTAI

›Specificity approaching 100%

›Accuracy 99.7%

›Negative predictive value 100%

›ACS Best Practices Guidelines support CTA as definitive study

›Protocol considerations

›IV contrast with arterial phase timing

›Multiplanar reconstruction for injury characterization

›Measure aortic diameter at injury and distal landing zones for TEVAR planning

›Evaluate for concurrent arch vessel involvement

›Chest X-ray limitation

›Classic CXR findings present in only 57.6% of confirmed BTAI

›Mediastinal widening in only 27.7% overall

›Normal CXR does NOT exclude BTAI

›Additional CXR findings: loss of aorticopulmonary window, rightward tracheal deviation, left apical cap, depression of left mainstem bronchus

›Pan-scan approach in polytrauma

›CT head, cervical spine, chest-abdomen-pelvis with contrast

›Identifies all competing injury priorities

›Most BTAIs in hemodynamically stable patients discovered on trauma pan-scan

›Follow-up CTA schedule post-TEVAR

›CTA at 1 month, 6 months, 12 months, then annually

›Monitor for endoleak, stent migration, device complications

›2026 SVS focused update recommendation

Ultrasound

›FAST examination

›Role and limitations in BTAI

›Low sensitivity for direct BTAI detection

›Cannot reliably detect mediastinal hematoma

›Valuable for detecting hemopericardium and hemoperitoneum

›Pericardial window

›Hemopericardium suggests ascending aorta or cardiac injury

›Tamponade physiology on echocardiography

›Pleural views

›Left hemothorax as high-risk feature for grade II injury

›Right hemothorax from concurrent pulmonary or vessel injury

›Transesophageal echocardiography

›Role of TEE in BTAI

›Useful bedside alternative in hemodynamically unstable patients

›When patient cannot be safely transported to CT

›2010 ACCF/AHA guidelines support TEE as imaging alternative

›Operator dependent; may miss distal aortic injuries

›TEE findings in BTAI

›Periaortic hematoma at isthmus

›Intimal flap or pseudoaneurysm

›Associated aortic regurgitation

›Intravascular ultrasound

›IVUS role as adjunct

›Equivocal CTA findings

›Intraoperative guidance during TEVAR

›Characterizes injury extent and landing zone anatomy

07Disposition/dispo36

ICU admission

›ICU admission indications

›All confirmed BTAI grades require ICU-level monitoring

›Continuous arterial line monitoring for anti-impulse titration

›Grades I-II: hemodynamic monitoring and serial CTA planning

›Grades III-IV: immediate surgical team involvement

›Monitoring requirements

›Continuous cardiac monitoring

›Hourly urine output via urinary catheter

›Neurologic checks every 1-2 hours

Operative disposition

›Operating room triggers

›Emergent OR: grade IV with hemodynamic instability

›Do not delay for additional imaging if CTA confirms grade IV

›Activate hybrid OR if TEVAR planned

›Urgent OR: grade III or high-risk grade II

›After stabilization of competing injuries

›Timing individualized with surgical team

›No outpatient management for any grade of BTAI

›All confirmed injury requires admission

Transfer criteria

›Transfer to aortic repair-capable trauma center

›Class I recommendation per 2022 ACC/AHA guidelines

›Initiate anti-impulse therapy before and during transfer

›Contact receiving center before departure

›Transport by air if > 60 minutes ground transport

›Do not transfer grade IV with refractory hemorrhage without operative stabilization

›Damage control thoracotomy at transferring center if needed

08Treatment/t76

Anti-impulse therapy

›Esmolol IV first-line agent

›Dosing protocol

›Loading dose 500 mcg/kg IV over 1 minute

›Initial infusion 50 mcg/kg/minute

›Titrate by 25-50 mcg/kg/minute every 5-15 minutes

›Maximum dose 300 mcg/kg/minute

›Targets

›Heart rate < 60 beats per minute

›Systolic blood pressure 100-120 mmHg

›Preferred for titrability and short half-life

›Labetalol IV alternative

›Dosing protocol

›Bolus 10-20 mg IV over 2 minutes

›Repeat every 10 minutes as needed

›Maximum cumulative bolus dose 300 mg

›Infusion 1-2 mg/minute

›Advantage: combined alpha and beta blockade

›Useful when additional afterload reduction desired

›Nicardipine IV for additional blood pressure control

›Dosing protocol

›Initial infusion 5 mg/hour

›Titrate by 2.5 mg/hour every 5-15 minutes

›Maximum 15 mg/hour

›Use only after adequate heart rate control achieved

›Vasodilator without rate control worsens aortic wall stress

›Clevidipine IV for additional blood pressure control

›Dosing protocol

›Initial infusion 1-2 mg/hour

›Double every 90 seconds to target

›Maximum 32 mg/hour

›Advantage: ultra-short half-life, easily titratable

›Nitroprusside IV only after beta-blockade established

›Dosing protocol

›Initial infusion 0.3 mcg/kg/minute

›Titrate by 0.5 mcg/kg/minute to effect

›Maximum 10 mcg/kg/minute

›Do NOT initiate before heart rate control

›Reflex tachycardia worsens aortic wall shear stress

Contraindications and precautions

›Anti-impulse therapy precautions

›Vasodilators before rate control are contraindicated

›Risk of reflex tachycardia worsening aortic wall stress

›Beta-blockers with caution in concurrent acute aortic regurgitation

›Bradycardia worsens regurgitant fraction

›Non-dihydropyridine calcium channel blockers if beta-blockers contraindicated

›Diltiazem 5-15 mg/hour IV infusion

›Verapamil 5 mg IV bolus every 15 minutes to maximum 20 mg

Resuscitation for hemorrhagic shock

›Massive transfusion protocol

›Component therapy ratio

›Packed red cells : FFP : platelets = 1:1:1

›Cryoprecipitate for fibrinogen < 1.0 g/l

›Tranexamic acid

›1 g IV over 10 minutes within 3 hours of injury

›Second dose 1 g IV over 8 hours

›Class I recommendation for hemorrhagic trauma

›Permissive hypotension in grade IV before operative control

›Target systolic blood pressure 80-90 mmHg

›MAP 50-65 mmHg until hemorrhage controlled

Operative management

›Thoracic endovascular aortic repair (TEVAR)

›First-line operative approach for grades III and IV

›Open repair decreased from 7.5% to 1.9% between 2007 and 2015

›30-day mortality 7.9% TEVAR versus 20% open repair

›Cochrane 2019 systematic review confirms TEVAR superiority for short-term outcomes

›TEVAR technical considerations

›Left subclavian artery coverage may be required

›Spinal cord ischemia risk: CSF drainage if prophylactically high risk

›Anticoagulation during TEVAR balanced against polytrauma bleeding risk

›Postoperative monitoring

›Spinal cord perfusion pressure monitoring

›Mean arterial pressure > 80 mmHg to protect spinal cord

›Open surgical repair indications

›Anatomy unsuitable for TEVAR

›Inadequate proximal or distal landing zone

›Small aortic diameter precluding available device sizing

›Failed TEVAR or endoleak requiring open conversion

›Thoracotomy with left heart bypass

›Aortic cross-clamp and graft interposition

09Special Populations/sp50

Pregnancy

›Pregnancy considerations in BTAI

›Physiologic changes affecting presentation

›Increased blood volume may mask hemorrhagic shock signs

›Supine hypotension from uterine compression of IVC

›Left lateral tilt positioning for resuscitation

›Fetal and maternal priorities

›Maternal resuscitation always takes priority

›Fetal monitoring after 24 weeks gestational age if uterus intact

›Obstetrics consultation for viable pregnancy

›Radiation considerations

›Do not withhold CTA for life-threatening aortic injury

›Fetal radiation dose from CT chest is < 1 mGy

›Benefit of diagnosis far outweighs radiation risk

›Operative planning

›TEVAR technically feasible during pregnancy with modification

›Consider cesarian section before aortic repair if fetus viable and uterus compromises operative field

›Contrast agents (iodinated) acceptable in pregnancy for life-threatening indication

Geriatric

›Geriatric considerations in BTAI

›Physiologic vulnerability

›Less compliant aorta increases injury severity for given mechanism

›Reduced cardiac reserve may mask tachycardic response to hemorrhage

›Pre-existing hypertension complicates anti-impulse therapy targeting

›Medication interactions

›Beta-blocker therapy may already be present

›Anticoagulant use increases bleeding risk during TEVAR

›Chronic renal impairment increases contrast nephropathy risk

10Background/b68

Epidemiology

›Incidence and mortality

›Second most common cause of death in blunt trauma patients

›Most die at scene from free aortic rupture

›Only 9-14% of patients with aortic rupture survive to hospital

›Untreated in-hospital mortality approximately 30% within 24 hours

›Injury site distribution

›Aortic isthmus most common injury site: approximately 45%

›Isthmus is transition zone between mobile arch and fixed descending aorta

›Ascending aorta injury second: approximately 8-15%

›Other thoracic aortic segments less common

›Mechanism distribution

›Motor vehicle collision is dominant mechanism

›Side-impact crashes account for approximately 44% of fatal aortic ruptures

›Falls from height and motorcycle crashes comprise remainder

›Hemodynamic status on arrival

›Hypotension present in 17-20% on ED arrival

›Majority of hospital survivors arrive hemodynamically stable

Pathophysiology

›Biomechanics of injury

›Deceleration and shear forces

›Rapid deceleration causes differential movement between mobile arch and fixed descending aorta

›Shear stress concentrated at aortic isthmus at ligamentum arteriosum

›Osseous pinch mechanism: aorta compressed between sternum and thoracic spine

›Hydrostatic pressure wave from abrupt thoracic compression

›Aortic wall anatomy and failure

›Intima fails first under shear stress

›Adventitia resists rupture and contains hematoma as pseudoaneurysm

›Grade IV represents adventitial failure with free hemorrhage

›Predisposing factors

›Pre-existing aortic pathology lowers injury threshold

›Connective tissue disorders reduce aortic tensile strength

›Atherosclerosis impairs wall compliance

›Pathophysiology of complications

›Pseudocoarctation physiology

›Periaortic hematoma compresses aortic lumen

›Upper extremity hypertension from proximal obstruction

›Lower extremity hypoperfusion and pulse deficits

›Spinal cord ischemia

›Artery of Adamkiewicz arises from T8-L2 intercostal vessels

›Intercostal coverage during TEVAR or open repair disrupts supply

›Anterior spinal artery syndrome: paraplegia with preserved proprioception

Therapeutic Considerations

›TEVAR versus open repair evidence

›TEVAR outcomes versus open repair

›30-day mortality: TEVAR 7.9% versus open repair 20%

›Paraplegia rates similar between approaches

›Stroke rates similar between approaches

›Long-term survival similar after index hospitalization

›Higher 1-year reintervention rate with TEVAR: 6% versus 0%

›Cochrane 2019 and JAMA Network Open 2019 data support TEVAR

›Timing of TEVAR

›Delayed repair preferred for grade III when patient stable

›Delay > 24 hours allows hemostasis, resuscitation, and injury prioritization

›Concurrent TBI may justify earlier TEVAR to allow BP liberation for cerebral perfusion

›Anti-impulse therapy evidence

›Cornerstone of nonoperative and bridge management

›Reduces aortic wall stress by lowering heart rate and blood pressure

›Class I recommendation per 2022 ACC/AHA and 2024 EACTS/STS guidelines

›IV esmolol preferred for titrability

›Blood pressure targets

›Heart rate < 60 beats per minute

›Systolic blood pressure 100-120 mmHg

›Based on expert consensus and registry data

›ICD-10 classification

›S25.0: injury of thoracic aorta

›S25.01: minor laceration of thoracic aorta

›S25.02: major laceration of thoracic aorta

›S25.09: other specified injury of thoracic aorta

›S25.1: injury of innominate or subclavian artery

›S27.1: traumatic hemothorax

11Patient Discharge Instructions/pdi32

copy discharge instructions

›Discharge instructions for traumatic aortic disruption

›Activity restrictions

›No strenuous physical activity until cleared by vascular surgery

›No lifting greater than 5 kg until follow-up appointment

›Driving restrictions as directed by surgeon

›Wound care if operative management

›Keep incision sites clean and dry for 48 hours

›Monitor for redness, swelling, warmth, or discharge

›Do not submerge incision in water until cleared by surgeon

›Medication instructions

›Take all blood pressure medications as prescribed

›Do not stop blood pressure medications without physician approval

›Antihypertensive adherence is critical for long-term aortic protection

›Blood pressure monitoring

›Home blood pressure monitoring twice daily

›Target systolic blood pressure < 130 mmHg long-term

›Record readings and bring log to follow-up appointment

›Follow-up imaging schedule

›Post-TEVAR: CTA at 1 month, 6 months, 12 months, then annually

›Nonoperative grade II: CTA at 1 month

›Do not miss surveillance imaging appointments

›Return to emergency department immediately for

›New or worsening chest pain or back pain

›Sudden severe interscapular pain

›Difficulty breathing or shortness of breath

›Syncope or near-syncope

›Weakness or paralysis of legs

12References/r34

Guidelines and key sources

›Primary clinical guidelines

›2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease

›Isselbacher EM, Preventza O, Hamilton Black III J, et al.

›Journal of the American College of Cardiology. 2022

›Comprehensive guideline covering BTAI classification and management

›2026 Society for Vascular Surgery Clinical Practice Guideline on Blunt Thoracic Aortic Injury: A Focused Update

›DuBose J, Kundi R, Curi MA, et al.

›Journal of Vascular Surgery. 2026

›Updated surveillance recommendations and grade-based management

›2024 EACTS/STS Guidelines for Diagnosing and Treating Acute and Chronic Syndromes of the Aortic Organ

›Czerny M, Grabenwöger M, Berger T, et al.

›European Journal of Cardio-Thoracic Surgery. 2024

›2025 Thoracic Trauma WSES-AAST Guidelines

›Coccolini F, Cremonini C, Moore EE, et al.

›World Journal of Emergency Surgery. 2025

Landmark studies

›Pivotal trial evidence

›Blunt Aortic Injury. Neschis DG, Scalea TM, Flinn WR, Griffith BP.

›New England Journal of Medicine. 2008

›Comprehensive review of BTAI pathophysiology and management

›Is Chest X-Ray a Reliable Screening Tool for BTAI? Crapps JL, Efird J, DuBose JJ, et al.

›Journal of the American College of Surgeons. 2023

›AAST/ATF prospective registry: classic CXR findings in only 57.6% of confirmed BTAI

›Systematic Review of TEVAR Versus Open Repair for Traumatic Ruptured Thoracic Aorta. Harky A, Bleetman D, Chan JSK, et al.

›Journal of Vascular Surgery. 2020

›TEVAR 30-day mortality 7.9% versus open repair 20%

›Long-term Outcomes of Endovascular and Open Repair for Traumatic Thoracic Aortic Injury. Cheng YT, Cheng CT, Wang SY, et al.

Evidence & Review

Evidence & Review